High yield things you need to know...
Coronaviruses (what are they?)
Most coronaviruses cause mild to moderate upper-respiratory symptoms. In fact, overall, they cause up to 30% of common colds. However, some have been historically identified to cause more severe symptoms such as pneumonia, acute respiratory distress syndrome (ARDS), organ failure and even death.
COVID-19 is pretty new. Like, younger than your Christmas tree that is probably still up. I mean, it didn’t even get a name until yesterday. So it is important to note that our current understanding of COVID-19 is limited to the clinical experiences since it was first identified in December, 2019. Therefore, much of the current recommendations are inferred by past experiences with other pandemic related Coronaviruses. Remember MERS and SARS? They are Coronaviruses too. MERS has been responsible for 850 deaths worldwide, and SARS killed 774 people before it was eradicated in 2004.
Originating in the Hubei province in china, COVID-19 has infected over 60,000 people and killed 1,300 in the first 2 months alone.
Before you freak out and move to the mountains…keep in mind that there are 59 million people that live in the Hubei province. If we are smart about this, hopefully we can contain the issue. The information in this article is largely summarized from the information listed on the CDC website. It is to serve as a high yield summary of must know information so we can help stop the problem, before it becomes our problem.
First, a few important things to consider about fever...
- Fever (for the purposes of COVID-19) is defined as EITHER a measured temperature > 100.0oF or a subjective fever.
- Yep…if the patient says they have been having fevers, and are an at-risk person, you chase that unicorn.
- Understand that fever may be intermittent or may not be present in some patients (elderly, immunosuppressed, or taking antipyretics).
How is it spread, you ask?
- We are pretty sure it’s passed by person-to-person through respiratory droplets.
- We don’t know if you can get if by touching surfaces with virus on it.
- Thought to be most contagious when most symptomatic.
- Incubation period of ~ 5 days (4-7 days) (Li Q, 2020).
- If you don’t have symptoms 14 days after a known exposure, you need to get back to work and pay your bills.
- We don’t know how long it remains infectious in the air.
Well, are the symptoms at lease specific?
- The clinical picture is not fully understood, but literature is already rolling out of china to help us get an idea.
- Severity can range from mild to severe.
- Fever, cough, myalgias and shortness of breath are the most common.
- Think Influenza, bronchitis, pneumonia (any lower respiratory tract infection).
- Less commonly symptoms include sputum production, headache, hemoptysis, and diarrhea.
- Some have described GI symptoms (nausea and diarrhea) before the onset of respiratory symptoms.
Fever: 83-98%
Cough: 46-82%
Myalgia or fatigue: 11-44%
Shortness of breath: 31%
Don’t these symptoms sound like just about every patient in the winter?
So, who do I even test for COVID-19?
The bottom line is…the patient needs to have respiratory symptoms WITH recent travel to china or close contact with a person known to have COVID-19. Close contact is considered spending an extended period of time within 6 feet of a person, or obviously anything more intimate than that. Certainly, consider that travel history importance may change if COVID-19 becomes more widespread worldwide. You can stay up to date by following the CDC website here.
CDC Disclaimer: “The criteria are intended to serve as guidance for evaluation. Patients should be evaluated and discussed with public health departments on a case-by-case basis. For severely ill individuals, testing can be considered when exposure history is equivocal (e.g., uncertain travel or exposure, or no known exposure) and another etiology has not been identified.”
Are we talking Ebola level outcomes here?
- Some are seeing a pattern of clinical deterioration during the second week of illness (Huang C, 2020).
- Highest rate of hospital admission seems to be around days 8-9 (Huang, 2020, Li Q, 2020).
- ARDS develops in up to 29% of hospitalized patients (Huang, 2020).
- Secondary infection develops in 10% (Chen, 2020).
- Up to 32% of hospitalized required ICU admission (Wang, 2020).
- 11% needed high flow oxygen
- 42% needed NIPPV
- 47% needed mechanical ventilation
- 10% of all admitted patients will need mechanical ventilation.
- In hospital mortality currently as high as 15%.
- All cause mortality is yet to be determined…did I mention this virus is pretty new?
and just for reference…Ebola kills 90% of those infected
Can we predict who will have bad outcomes?
Short answer is, we don’t really know yet. Although older patients and those with chronic medical conditions may be at higher risk (…no duh).
How do I work it up?
Lab Values
- Leukopenia (9–25%)
- Leukocytosis (24–30%)
- Lymphopenia (63%)
- Elevated LFTs (37%)
- Procalcitonin is usually normal
Imaging
- Chest CT images have shown bilateral involvement in most patients.
- Multiple areas of consolidation and ground glass opacities are typical findings being reported.
Standard labs don’t seem to be of much help for diagnosis, but needed to look for end organ injury.
Viral PCR
- Data is limited.
- We are definitely finding the virus in upper and lower respiratory specimens.
- We are sometimes finding it in blood and stool, but clinical infectivity of these isolates are still unknown.
- Duration of detection if the respiratory tracts is unknown.
- Information on specimen collection, handling, and storage is available at: Real-Time RT-PCR Panel for Detection 2019-Novel Coronavirus.
To increase the likelihood of detection, the CDC recommends collecting and testing multiple clinical specimens from different sites, including two specimen types – lower respiratory and upper respiratory (i.e., sputum and nasal swab).
So, can I treat it?
- There are currently no antiviral drugs licensed by the FDA to treat COVID-19.
- Clinical management includes prompt recognition and infection control measures.
- Patients are treated with supportive management of complications.
- Patients with a mild clinical presentation may not initially require hospitalization…but expect the clinical condition to worsen around day 8.
- The decision to monitor a patient in the inpatient or outpatient setting should be made on a case-by-case basis in consultation with infectious disease personnel.
- Avoid Corticosteroids unless indicated for other reasons (COPD or Septic Shock) because of the potential for prolonging viral replication seen with MERS patients (Zumla, 2015).
- There are ongoing trials looking at the use of Remdesivir for COVID-19, but no date is available at the time of writing this article…so stay tuned.
What kind of isolation is needed?
- For now, the CDC recommends treating this like any other bad airborne pathogen (measles, tuberculosis, etc.).
- Use normal hand hygiene and cough etiquette.
- Call ahead if you are expecting a patient of interest at a certain facility. Nobody wants to be surprised by a COVID-19 patient coughing up a busy ED waiting room in the middle of flu season.
- Don’t keep the patient in the waiting room–and keep them 6 or more feet away from other people. The CDC suggests keeping stable patients in their own vehicles and then calling them by mobile phone when ready for medical evaluation. Like a fancy restaurant.
- Patient should wear a facemask at all times.
- Single patient rooms at negative pressure.
- Room doors should be kept closed except when entering or leaving the room.
- Room entry and exit should be minimized.
- If a negative pressure room is not available, patients who require hospitalization should be transferred as soon as is feasible to a facility where a negative pressure rorom is available.
- The patient’s facemask may be removed when in negative pressure (but I say, why risk it).
- Patient definitely needs to wear a facemask if transporting.
- Keep a log of all people who enter or exit the room.
- Restrict visitors from entering the room of known or suspected COVID-19 patients.
What is the appropriate PPE?
- Gloves
- Gowns–regular cloth or disposable ones.
- Minimum of an N95 respirator. Use a PAPR if don’t have fit-tested NIOSH-certified N95 masks.
- Clean the PAPR according to manufacturer recommendations after each use.
- Eye protection–goggles or face shield.
How do I report a suspected infection?
- If you suspect a COVID-19 infection, immediately notify both the infection control personnel at your facility and your local or state health department.
- State health departments will then contact the CDC’s Emergency Operations Center (EOC) at 770-488-7100 and complete a COVID-19 case investigation form available here.
What if I am exposed?
Medium or High-Risk exposure à you are monitored like a rabid dog for 14 days and you can’t work.
Low-Risk exposure à you check yourself twice a day for a fever and if you develop a cough or fever, you turn yourself in, but you can keep working.
These situations are considered medium to high risk and require active monitoring (state or local public health authority monitoring)and restriction from work in any healthcare setting until 14 days after their last exposure. (Copied from the CDC website)
- Healthcare personnel (with unprotected eyes, nose, or mouth) who perform or are present in the room for a procedure likely to generate higher concentrations of respiratory secretions or aerosols (e.g., cardiopulmonary resuscitation, intubation, extubation, bronchoscopy, nebulizer therapy, sputum induction).
- Healthcare personnel (who perform or are present in the room for a procedure likely to generate higher concentrations of respiratory secretions or aerosols (e.g., cardiopulmonary resuscitation, intubation, extubation, bronchoscopy, nebulizer therapy, sputum induction) and not using a gown and gloves.
- Healthcare personnel (with unprotected eyes, nose, or mouth) who have prolonged close contact with a patient who was not wearing a facemask.
- Healthcare personnel(with unprotected eye, nose, and mouth)who have prolonged close contact with a patient who was wearing a facemask.
- Healthcare personnel (not wearing gloves) who have direct contact with the secretions/excretions of a patient and the Healthcare personnel failed to perform immediate hand hygiene.
These situations are considered low risk and require self-monitoring with delegated supervision (this means you check yourself for fever twice daily with oversight by your healthcare facility’s occupational health) and do NOT need to be excluded from work. (Copied from the CDC website)
- Healthcare personnel wearing a facemask or respirator only who have prolonged close contact with a patient who was wearing a facemask.
- Healthcare personnel using all recommended PPE (i.e., a respirator, eye protection, gloves and a gown) while caring for or having contact with the secretions/excretions of a patient.
- Healthcare personnel (not using all recommended PPE) who have brief interactions with a patient regardless of whether patient was wearing a facemask (e.g., brief conversation at a triage desk; briefly entering a patient room but not having direct contact with the patient or their secretions/excretions; entering the patient room immediately after they have been discharged).
- Healthcare personnel who walk by a patient or who have no direct contact with the patient or their secretions/excretions and no entry into the patient room.
Can a COVID-19 patient be discharged home?
Can the patient be discharged home?
- Only in consultation with state or local health department staff.
- Home setting must be appropriate for home care.
- Considerations for care at home include whether:
- Patient has to be stable.
- Appropriate caregivers are available at home.
- There is a separate bedroom where the patient can recover without sharing immediate space with others.
- Resources for access to food and other necessities are available.
- Access to appropriate, recommended personal protective equipment (at a minimum, gloves and facemask)
- Capable of adhering to respiratory hygiene, cough etiquette and hand hygiene.
- No household members who may be at increased risk of complications (age > 65 years old, young children, pregnant women, immunocompromised people or those with chronic heart, lung, or kidney disease).
Discharge Instructions:
- Stay home except to get medical care.
- Separate yourself from other people in your home.
- Call ahead before visiting your doctor.
- Wear a facemask.
- Cover your coughs and sneezes.
- Clean your hands.
- Avoid sharing personal household items.
- Monitor your symptoms.
- Anticipate worsening symptoms around day eight.
- Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet. 2020 Jan 24.
- Wang D, Hu B, Hu C, Zhu F, Liu X et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan. Published online February 7, 2020.
- Chen N, Zhou M, Dong X, Qu J, Gong F. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020 Jan 30. China. The Lancet. 2020 Jan 24.
- Zumla A, Hui DS, Perlman S. Middle East respiratory syndrome. Lancet. 2015 Sep 5;386(9997):995-1007. doi: 10.1016/S0140-6736(15)60454-8. Epub 2015 Jun 3. Review.
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